Procedural sedation

Sedation Levels

• Minimal Sedation
  • Pain meds
• Moderate Sedation
  • Pt awake, pt able to respond to questions
  • LP, I+D
• Deep Sedation
  • If give pt painful stimuli they will react purposefully
  • Usual goal
• General Anesthesia
  • Unarousable

Versed/Fentanyl

• Designed for moderate sedation
• If titrate to deep sedation, when the painful stimulus stops they may become apneic (stimuli not matching the level of sedation)
• Lasts for 30min

Important to put pt in position you would intubate them (ear at level of sternal notch) Consider nasal airway in pt with likely OSA

(ETCO2 + O2) - bad if CO2 becomes very high OR very low

or room air

If need extended time procedural sedation, completely pain free, muscles relaxed, but want pt spontaneously breathing, any of the deep sedation agents are tough: sooooo consider dissociation

Ketamine 1-1.5mg/kg slow IVP, ---- very safe pt may become apneic for 20s, always resolves Emergence - not necessarily a bad thing (can have good emergence) Pretreatment necessary? - atropine or glycopyrrlate? Nah Emergence pretreatment? No, just give versed if it happens consider versed 1-2mg prior for amnesia (pt maybe doesn't want to remember tripping out)

Sympathomimetic - avoid in old, hypertensive, baseline crazy/psych

Etomidate + fentanyl Good for brief sedation if don't have propofol shoulder/hip reduction, cardioversion for short lived but painful procedure Dose fentanyl first: 0.5-1mcg/kg analgesia Etomidate 0.15mg/kg (8-10 on avg.. if not enough then give additional 4mg boluses) by 6 min wears off sedation of profound sedative agent matches the length of time of the stimulus Hemodynamically stable for pt

just like versed/fentanyl but better b/c it disappears faster what about myoclonus? - usually mild either let it wear off or can try to give versed to stop it

Side effects

Dropping sats - 1. Stimulate 2. Jaw thrust 3. Nasal airway 4. BVM (just 10 breaths/min) count to 5 between breaths 5. NIV 6. LMA 7. Intubation